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SAN JOAQUIN Environmental Health Department <br /> COU ,TY <br /> HAZARDOUS MATERIALS DISCLOSURE SURVEY <br /> A separate survey form is required for each business name and/or address in San Joaquin County, <br /> Business Name: San Joaquin Regional Transit <br /> Telephone: ( Z 9 9SS— aa/r 2 0 <br /> Business Site Address: 120 North Filbert Street,Stockton,CA 95205 <br /> Mailing Address if different from above): 2601 Navistar Drive,Lisle, IL 60532 <br /> Business Owner($) Name: National Express,LLC Telephone: (630)821-9058 <br /> Business Owner Address: 2601 Navistar Dr,Lisle, IL 60532 <br /> Nature of Business: Regional Transit Operations Stockton Fire <br /> Flre District: Department <br /> Q1. o Vag 11 No Don your business handle a hazardous material in env quantity at any one time in the year? <br /> See the definition of hazardous material on page 2 of this form. <br /> o Yes �S No Does your business generate,treat,or store a hazardous waste imanvguanfly?(used oil,used <br /> antifreeze,waste solvent,etc.) <br /> If your anewar is"No"to both questions In Q1,please print,sign,and data the bottom of mis form and return to the address above. <br /> 02. )p Yes oNo Does your business handle a hazardous material,or a mixture containing a hazardous material, <br /> in a quantity equal to or greater than 55 gallons, 500 pounds,or 200 cubic feet at any one time <br /> in the year? <br /> If"Yes",how long have you handled these materials at your business? `11 year <br /> If"Yea,check any of the following conditions that apply to your business: <br /> o A. The hazardous materials handled by this business are contained solely in a consumer product <br /> Packaged for direct distribution to and use by the general public. <br /> n B. This business operates a farm for purposes of cultivating the soil, raising or harvesting an <br /> agricultural or horticultural commodity. <br /> 03. in Yes N No Does your business handle an Acutely Hazardous Material? See definition on page 2. <br /> Q4. c Yes k No is your business within 1,000 feet ofthe outer boundary of a school?(Grades K-12) <br /> 1 have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety <br /> Code(HSC). I understand that if I own a facility or property that is used by tenants,it is my responsibility to notify the tenants of the <br /> requirements which must be mel prior to Issuance of a Certificate of Occupancy or beginning of operations. I declare under the <br /> penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> If you answered"Yes'to Question 2,please go online to cars cal ra o to submit your hazardous materials information. <br /> Owner or Authorized Agent: 1 <br /> Print Name: Betz' v ki J p 4)4 <br /> Signature: f�/J Title: &/—e ' e / ✓ "y 42' <br /> C V- <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 458-3420 1 F 209 464-0138 1 www.sjcehd.com <br />